Transcript Neurosensory: Herniated Disk and Spinal Cord tumors

Neurosensory Disorders: Stroke
(CVA, Brain Attack)
Marnie Quick RN, MSN, CNRN
A. Pathophysiology/etiology
Normal brain physiology and stroke
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Ranks 3rd as cause death
Blood supply to one
hemisphere is typically
blocked, hence terms
right & left stroke
Functioning brain
depends on continuous
blood supply for oxygen
and glucose & remove
end products metabolism
Risk factors for stroke:
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Nonmodifible- age,
gender, race, family
history/heredity
Modifible:
hypertension*;
atherosclerosis* heart
disease; DM; medication
(birth control, substance
abuse-cocaine/heroin and
alcohol; sedetary life
style obesity; high
cholesterol diet; smoking;
stress; sickle cell disease
Brain dysfunction &
length of time without blood supply
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Brain function depends on collateral circulation and
amount of cerebral edema
TIA- neuro deficits last < 24 hrs
RIND- neuro deficits last > 24 hrs but reverse not greater
than 21 days
CVA- irreversible brain damage with residual neuro
deficits
Stroke-in-evolution- progressive neuro deficits
developing over hours or days. Usual cause thrombosis
Two basic disease process causing stroke
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Ischemic stroke- 80%
 Occlusion of artery
 Generally do not
lose consciousness
 Better prognosis
than hemorrhagic
 May have TIA’s
before
 Thrombosis or
embolism
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Hemorrhagic stroke- 15%
 Bleed occurs with
activity
 Usually rapid onset
 Generally loss of
consciousness
 Poorer prognosis
 Intracranial or
subarachnoid
Ischemic stroke:
Thrombosis
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Most common cause of a stroke (60%)
Cause- narrowing of artery from atherosclerotic plaques
Blood is blocked to part of brain that the artery supplies
Often occurs in older individuals who are at rest/sleeping
Tend to form in large arteries that bifurcate, internal
carotid artery common site
Can begin as TIA’s, present as stroke-in-evolution, or
have completed stroke outright
Lacunar strokes are strokes affecting smaller cerebral
vessels in brain- they leave a cavity or ‘lake’
Ischemic stroke
Embolism
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Caused by: clotted blood from other arteries in
the body (heart during atrial fibrillation) fat,
bacteria (endocarditis) or air
Emboli circulate until reach an artery in brain that
is too narrow to pass through
Usually awake with rapid onset
Extent damage is less severe and recovery faster
than other strokes
Will recur if don’t treat cause
Hemorrhagic stroke
Intracranial hemorrhage (ICH)
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Caused by ruptured artery in the brain
Bleeding varies in size from petechial to massive, edema
occurs around the bleed
Blood may form hematoma or be diffuse within the brain
Usually occurs rapidly with the deep arteries
Hypertension is main cause
Most common cause of death due to a stroke
Have more extensive residual deficits and slower recovery
than other causes of stroke
Hemorrhagic: Subarchnoid hemorrhage
(SAH)
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Caused by bleeding into
subarchnoid space from
 Extension of a
intracranial
hemorrhage
 Aneurysm
 AV malformation
Usually occur in younger
adults 30-60 than other
strokes
Hemorrhagic: SAH Aneurysm
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Occur at bifurcations,
branches of carotids &
vertebrobascular arteries
85% base brain in
anterior circulation
Most common type is
berry-bleed from dome
Caused by trauma,
congential,
arteriosclerosis
Hemorrhagic: SAH- Aneurysm
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Aneurysms are graded 0-V on the Hunt/Hess
scale; higher the number, poorer chance survival.
Based on LOC & quality of cerebral function
Aneurysm are usually asymptomatic until rupture
Ruptured- sudden explosive headache; loss of
consciousness; N & V; nuchal rigidity (stiff neck)
and photophobia from meningeal irritation;
cranial nerve deficits
Major complications: rebleed, vasospasms, and
hydrocephalus
Hemorrhagic: SAH
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Congential abnormal
joining of arteries to
veins in the brain.
As pressures changes
occur becomes tangled
collection of dilated
vessels.
Ischemia symptomsseizures and interference
with normal function of
those brain cells
A-V malformation
Common manifestations/complicationsby body systems
By artery affected by occlusion or hemorrhage
Internal carotid
Middle cerebral artery
Middle cerebral artery
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Contralateral motor loss
in the arm and the lower
part of the face (central
facial palsy)
Contralateral sensory
loss in face and arm
Homonymous
hemianopsia
Left middle cerebralcommunication deficits
Right- spatial/perceptual
Other main arteries off Circle of Willis
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Anterior cerebral
Posterior cerebral
Verebrobasilar
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Pain or numbness of
involved side
Vertigo
Contralateral ataxia
Dysphagia, dysarthria
Cranial nerve
dysfunctions
Common Manifestations: Motor deficits
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Motor nerve pathways cross in the medulla
(brainstem) Prefix hemi- used to describe.
Extremities not affected equally- middle cerebral
Amount of motor involvement varies from
weakness (-paresis) to paralysis (-plegia).
End paralysis can be flaccid or spastic depending
on amount of damage to the motor strip
Initially flaccid and if progress are spastic in 6-8
weeks.
Motor deficits- Characteristic body posture
Motor deficits
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Facial palsy(central/UMN) where
lower part face
affected
Bells palsy (LMN- 7th
CN) where the whole
side of face affected
Dyphagia- difficulty
swallowing
Sensory-perceptual deficits
Lack of sensation/propriocetion
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Lack of sensation (hemi)- inability to
perceive/interpret pain, touch, pressure (post
central gyrus)
Lack of/decrease in proprioception or the
inability to know where body part is without
having to look at it; body’s ‘position sense’
Sensory-perceptual deficits
Visual field deficits
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Disruption anywhere
along the pathway
Homonymous
hemianopsia- most
common. Loss of half
of visual field in each
eye. Can’t see toward
the same side as the
paralysis
Homonymous hemianopsia
What the patient sees
Communication Deficits
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Motor, speech, language, memory, reasoning, emotions
can be affected
Dominant hemisphere for the communication centers is
left in most individuals
Global (mixed) aphasia- both expressive (Broca’s area)
and receptive (Wernicke’s area) aphasia
Aphasia- total loss of comprehension or use of language
Dysphasia partial loss or difficulty with communication
Dysarthria- difficulty with articulation or muscular
control for speech. Sound like have mashed potatoes in
their mouth
Communication Deficits
Broca’s and Wernicke’s aphasia
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Broca’s, expressive or
nonfluent aphasia
where unable to
express- but
understands
Wernicke’s,
receptive, fluent
aphasia- can talk but
unable to understand
Broca speech area
Wernicke speech area
Communication Deficits
Normal process recovery
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Begin with one word speech- swearing,
‘ouch’
Progress to sayings – days of week, social
speech, singing
Volitional- normal speech
Recovery may stop at any point, depending
on the amount of damage to speech centers
Affect and intellectual deficits
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Change level consciousness- confusion to coma
Emotional lability- exaggerated, unpredictable
emotional responses. Physiological in nature
Loss of self control, decrease tolerance for stress
Depression, frustration (esp left CVA)
Intellectual changes resulting in memory loss,
decreased attention span, poor judgment, inability
to think abstractly and make generalizations
Sensory-perceptual deficits
Neglect syndrome (unilateral neglect)
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Attention disorder in which individual ignores
affected part of the body,
Cannot integrate or use perceptions from affected
side or from the environment from that side
May observe head turned away from neglected
side, does not dress that side, neglects people
objects on that side. Diff judging distances
More common in right CVA’s; patient may not
be aware of deficit
Sensory-perceptual deficits:
Agnosia
Apraxia
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Inability of the senses
to perceive stimuli
that were previously
familiar.
May be any of the
senses and varying
degrees
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Inability to carry out
purposeful task in the
absence of paralysis
Or the individual
carries out task
inappropriately
Elimination Deficits
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Partial loss of sensation (hemi) can affect
perception of need to eliminate bowel/bladder
Cognitive problems may affect the social aspect
of elimination
Level of consciousness, immobility, dehydration,
diet changes
Immobility complications of Stroke
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Any of the immobility complications can occur!
Orthostatic hypotension
Thrombus formation
Impaired respiratory function
Formation of renal calculi
Decreased CO
Osteoporosis
Decubitus ulcer
Contractures
Collaborative Care for Stroke
Diagnostic tests
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CT- Most important initial- within 25 min Read 45min
indicate size location of lesion; differentiate ischemic
from hemorrhagic. PET- cerebral blood flow and
metabolic activity
MRI or MRA (combined MRI with arteriogram)
Cerebral blood flow
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Arteriogram- abnormal structures; vasospasm, stemosis
Transcranial ultrasound doppler velocity of blood flow, degree
of occlusion
Cardiac assessment: EKG; cardiac enzymes
Other: LP- obtain CSF, ck bleeding; Blood studies-CBC,
glucose, lipid, platelets
Collaborative Preventive care- Manag of
modifiable risk factors- medications/surgical
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Lewis p1466 Table 58-5 prevention of stroke
guidelines and specific treatment for modifiable
risk factors with:
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medication- treat hypertension, DM, cardiac
problems, etc
life style changes: smoking, dietary changes treat
hypertension, DM, cardiac problems, etc
Preventative treatment with surgery, such as
carotid endarterectomy, stenting
Carotid Endarterectomy
Brain stent to treat blockages in cerebral
blood flow
Collaborative Acute Care:
Emergency Management of a Stroke
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Lewis p. 1468 Table 58-6
Etiology
Assessment findings
Interventions
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Initial
Ongoing
Collaborative Acute Care:
Thrombolitic stroke
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Medication
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Thrombolitic agents to dissolve clot- 3 hrs!!! tPAActivace. Protocol prior to giving as R/O bleed
Anticoagulants to prevent further extension
Antithrombolitic inhibit platelet phase of clot
formation (Ticlid, Plavix, aspirin)
Anticonvulsants prevent seizures from focus
Surgical
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Endarterectomy
Angioplasty, carotid artery stenting
Bypass superficial temporal to middle cerebral
Collaborative Acute Care:
Embolic/intracranial stroke
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Embolic stroke
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Medications: If blood clot- anticoagulants,
thrombolitic agents, antiarrhythmics; If bacterialantibiotics
Surgical- Embolic retrieval (Merci retriever)
Intracranial hemorrhage (ICH) stroke
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Bedrest
Medication- antihypertensives to normal BP
Surgery- remove hematoma if possible
Merci retriever to remove cerebral clot
Collaborative Care:
Intracranial Hemorrhage (ICH)
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Bedrest
Medication- antihypertensives
Surgical- If hematoma remove
Collaborative Care: SAH
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Aneurysm precautions- decrease external/internal stimuli
Medications
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Aide with aneurysm precautions- stool softners, antinausea,etc
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To prevent rebleed/lysis of clot- Ammicar
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To prevent vasospasms- Nimodipine
 Before OR- Ca channel blocker- Nimodipine
 After OR-triple H- vasodilators (Isuprel); induced arterial
hypertension (Dopamine); hypervolemic hemodilution
(Albumin)
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Prophylactic antiepileptic- Cerebyx/Dilantin
SAH- Common manifestation/complications
Major complications
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Rebleed due to
reabsorption of the clot
that is stopping the bleed
Vasospasms due to
irritation of the blood
vessels
Hydrocephalus from
blockage of normal
absorption of CSF
Surgical intervention:
Clipping and Wrapping of Aneurysms
Surgical:
GDC Coil
SAH A-V malformation
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Embolization, ligation of
feeders, laser surgery to
remove
Gamma Knife- radiation
to reduce size of A-V
malformation>
Cyberknife below
Collaborative Rehabilitation Care
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Physiatrist (rehab physician): Outpatient or inhouse rehab
Physical therapy; Occupational therapy; Speech
therapy; Cognitive therapy, etc
Exercise program
Outpatient, in-house rehab, nursing home
Home evaluation
Encourage self-care
Community resources
Family support
Nursing assessment specific to stroke
Health history & physical exam
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Subjective data: Lewis 1472 Table 58-7
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Health history- Risk factors; when symptoms began;
describe symptoms; current medications
(legal/illegal); other health problems; family history
Objective data
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General; respiratory; cardiovascular; GI; urinary;
neuro; Vital signs; neuro vital signs (LOC, pupils,
motor, sensory)
Level of consciousness- Refer to Module 10
Nsg assess- neuro deficits common in stroke
Motor
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Movement, strength (with & without resistance),
symmetry of all extremities
Pronator drift- detects weakness of upper
extremity. Hold arms, palms up in front with eyes
closed- should be able to hold for 30 seconds.
Weakness pronates and drifts downward
Use similar techniques used to assess motor SCImotor pathways affected begin motor strip brain
Test facial movement- smile/frown test for Bell’s
(7th CN) and central facial (motor strip)
Nursing assess- neuro deficits common stroke
Motor
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EOM’s- head still, follow
your finger in all
quadrants. Eyes should
move together (conjugate
gauze) Abnormal:
dysconjugate gauze;
nystagmus; 3rd nerve
palsy (occulomotor); 6th
nerve palsy (abducens)
Nursing assess neuro deficits: Motor
3rd nerve palsy
6th nerve palsy
Nursing assess- neuro deficits common stroke
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Assess tongue deviationstick out tongue
Ability to swallow, gag,
Dysphagia- difficulty
swallowing
Assess ability to void and
move bowels
Assess communication
ability
Assess cognitive and
behavioral aspects
Nursing assess-neuro deficits common stroke
Sensory deficits
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Superficial sensation
With paperclip and
eyes closed alternate
sharp and dull ends
Reference is the
sensory strip on the
parietal side
Nursing assess- neuro deficits common stroke
Sensory
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Proprioceptionposition sense
With eyes closed and
hoding the toe on the
sides, move toe up &
down (not touching
the other toes), stopthen ask is toe up or
down
Nursing assess- Sensory: visual field loss
common- homonymous hemianopia
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Patient look straight
ahead & in a still
position, cover one
eye- test one at time
Move your wiggling
finger into the
patients field of
vision in all 6
quadrants
State when 1st sees
Nursing assess- neuro deficits common stroke
Sensory-perceptual
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Visual agnosia: individual becomes lost on unit;
cannot read sign/symbols; difficulty estimating
distance (spills food); cannot find objects; does
not recognize faces on photo or own image
Auditory agnosia: ind appears bewildered by
sounds; and does not respond approp- phone
ringing; can’t identify sound as running water
Tactile agnosia- with eyes closed can’t recognize
familiar objects- comb, pencil; unaware location;
diff positioning self- slouches to one side
Nsg assess- neuro deficits common stroke
Sensory-perceptual
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Apraxia- stares at food tray unaware of how to
get food to mouth; combs hair with toothbrush;
puts shirt on legs
Unilateral neglect; ignores paralyzed arm or leg;
may claim it is not theirs; bumps into wall as
going down hall; unaware of objects place on
paralyzed side
Loss of postural stability>>
Loss of postural stability. Unable to sit upright
and tends to fall sideways
Nursing assessment specific to stroke
National Institute Health (NIH) stroke scale
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An assessment scale to reflect the degree of
neurologic dysfunction specifically for stroke
Based on level of consciousness, gaze, visual,
facial palsy, motor, ataxia, sensory, language,
dysarthria, and extinction and inattention
(neglect)
Know how to test for each aspect using the tool
found on the website:
http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf
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NIH Stroke Score guidelines measuring stroke severity:
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0= no stroke
 1-4= minor stroke
 5-15= moderate stroke
 15-20= moderate/severe stroke
 21-42= severe stroke
 A maximal score of 42 represents the most severe
and devastating stroke.
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As of 2008 stroke patients scoring greater than 4 points
can be treated with tPA. -If meet other protocalcriteria
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http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf
Pertinent Nursing problems/interventions
Lewis p.1473 NCP 58-1
1. Ineffective tissue perfusion (cerebral)
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Monitor resp status; provide O2; suction needed
Monitor neuro, specifically increasing neuro
deficits, seizures, and ICP(Module 10); HOB 30
degrees
Monitor cardiac status, esp dysrhythmias
If individual unconscious- coma care
2. Ineffective airway clearance
Nursing problems/interventions
3. Impaired physical mobility
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Encourage active (when possible)& passive ROM
Change position every 2 hrs, esp if comatose
Monitor/prevent thrombophlebitis
Work with Rehab team
Arm sling- used to prevent subluxation of the
shoulder from a paralyzed arm when OOB
Splints- hand/foot to prevent contractures; set up
schedule- on 2 hrs off 2 hrs- use ROM
Assistive devices
Nursing problems/interventions
4. Impaired verbal communication
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Assess speaking, writing, gestures, understanding
Support speech therapist plan
Support guidelines
Swearing may be first sign of return of speech,
not directed at you or family
5. Unilateral neglect
6. Impaired urinary elimination
Pertinent Nursing problems/interventions
7. Impaired swallowing
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Dysphagia- impaired swallowing
Provide safety when eating! Assess ability, head
of bed up; begin with food of consistency; food
on unaffected side; have pt think swallow
Occupation therapy and /or speech therapy can
evaluate the individuals ability to get food to
mouth and to swallow
Swallow studies
Nursing problems/interventions
8. Low self-esteem
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9. Self-care deficit
Enourage use of paralyzed extremity
Teach dsg tech- affected arm in clothing first
Work with rehab team regarding ADL’s, use of
assistive devices, plans for progress, home care
Allow time and encouragement ADL’s
Assess both physical & cognitive ability ADL
With agnosia encourage pt use other senses
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With apraxia- break complex tasks down into simple
steps; have a single item out at one time; use colored
labels on clothes or velcro on one sleeve; allow time;
encourage independence
Perseveration- may have to tell person to stop action that
they are perseverating about or may have to physically
stop them
Homonymous hemianopsia in acute phase approach from
the sighted side; as client progresses- teach/encourage to
scan room and place objects on unsighted side
Pertinent Nursing Problems:
Nursing Management of the following:
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Health promotion
Respiratory system
Neurologic
Cardiovascular
Musculoskeletal
Integumentry
Gastrointestional
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Urinary system
Nutrition
Communication
Sensory-perceptual
alterations
Affect
Coping
Pertinent Nursing Problems:
Ambulatory and Home Care
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Rehabilitation
Musculoskeletal
function
Nutritional Therapy
Bowel function
Bladder function
Sensory-Perceptual
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Affect
Coping
Sexual function
Communication
Community
integration